25._CCHCS-MC-332-_Contractor_Contact_Information.pdf
PDF 78 KB Posted
- Attached to
- SD23-00088 Ocular Prosthetic Services (Region 4)
- Solicitation number
- 0000032627
- Issued by
- San Bernardino County, California
About this file
This document is a Contractor Contact Information form related to a state contract opportunity issued by the California Department of Corrections and Rehabilitation (CDCR) for Ocular Prosthesis services. The form requires the contractor to provide their company name, authorized representative, telephone number, and fax number, which will be used by CDCR institutions and facilities to contact the contractor and request services. The contractor must submit a new form if there are any changes to the contact information provided. A separate form is required for each service type awarded under the contract.
The document does not provide details on the scope of work, quantities, response dates, award dates, or contract term. It only focuses on the contractor contact information required for the awarded contract.
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Text version
Bid Number: SD23-00088
Attachment 25 CCHCS-MC-332 – Contractor Contact Information Rev. 11/01/2017
CONTRACTOR CONTACT INFORMATION
The information provided below is included on the award matrix posted on the California Department of
Corrections and Rehabilitation Internet website. This information is used by institutions/facilities to contact your company to request services. It is the contractor’s responsibility to submit a new form to California
Correctional Health Care Services (CCHCS) if there are any changes to the telephone number and/or fax number provided below. If your company was awarded a contract for more than one service, then a separate form for each service type is required. Submit the completed form(s) to the CCHCS Direct Care
Contracts Section Help Desk at: cchcshealthcarecontractshelpdesk@cdcr.ca.gov.
Type of Service: Ocular Prosthesis
Company Name: (Must be identical to the payee’s legal business name listed on the STD 204)
Telephone Number: Fax Number:
Name of Authorized Representative: Title:
Signature of Authorized Representative: Date:
mailto:cchcshealthcarecontractshelpdesk@cdcr.ca.gov
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